【作者】 许传华；

【导师】 彭万年；

【作者基本信息】 广州中医药大学 ， 中医临床基础， 2012， 博士

【摘要】 糖尿病周围神经病变是糖尿病最常见的并发症之一,可累及感觉神经、运动神经及植物神经出现功能障碍,尚无有效措施阻止其发展。仲景经方是祖国医学临床实践的宝贵经验结晶,因其法度严谨、配伍精妙、用药精准、疗效卓著而倍受推崇,堪称群方之祖。本研究就是在分析中医药文献的基础上,结合现代统计学方法,对伤寒经方治疗糖尿病周围神经病变临床资料进行的总结性研究。具体主要研究内容和结果如下：一、中医药文献研究首先从全面归纳整理糖尿病周围神经病变的中医药文献入手,从中医学病因病机、临床辨证分型和治疗用药,包括特色疗法、外治法、针灸疗法等的情况系统做了分析,同时对仲景经方发展的历史渊源,历代的特殊性贡献以及近现代的发展情况全面探讨,为本研究的进一步展开奠定了文献学基础。二、中医证治规律研究1、研究目的本研究利用现代统计学方法对仲景经方治疗糖尿病周围神经病变临床资料从中医学诊断、治疗方面多角度展开了研究,并对其进行的阶段性总结和进一步系统整理研究发掘。2、研究方法我们以中国全文期刊数据库(CNKI)及中国科技全文期刊(维普)医学专业数据库作为主要目标检索对象,以仲景经方“黄芪桂枝五物汤”、“当归四逆汤”、“肾气丸”三方证作为经方代表,规范数据,建立数据库,运用频数分析、因子分析、卡方检验比较分析等医学统计学方法进行了系统研究。3、研究结果在仲景经方治疗糖尿病周围神经病变临床资料的中医学诊断方面,在频数分析巾,症状出现频率大于5%的黄芪桂枝五物汤方证有17个,当归四逆汤方证有16个,肾气丸方证有22个。通过因子分析研究潜在的方证构成影响因素,结果发现黄芪桂枝五物汤方证有肢体局部不适、气虚不适、肌肤卫表不调以及胃肠不适四方面,当归四逆汤方证有局部不适,气虚阳虚不适,胃脘不适以及气血循环不畅四方而,肾气丸方证有局部不适,肾阳虚症,气虚不适,胃肠不适,神经精神症状五方面。再进一步运用卡方检验对仲景经方三方证共有的局部麻木、局部疼痛、肢体活动不灵、畏寒肢冷、神疲乏力、腹胀、口淡不渴、头晕、而色无华9个症状进行比较,结果发现心部麻木、局部疼痛、肢体活动不灵3症状未见明显差异。仲景伤寒经方治疗糖尿病周围神经病变的药物情况方面,在原方药物使用上,随疾病和时代变化也出现了新特点,比如原方原量使用情况较少,同时也发现桂枝一味药物使用频率极高。在配伍加减药物情况方面,统计发现,理论频数大于5%的药物有54味,经过卡方检验两两比较除外三经方证原方药物影响因素未见明显差异,参考中药学教材分类标准发现,补虚类药物有14种最多,其次活血化瘀类药物11种,祛风湿药7种、清热药6种、解表药5种、利水渗湿药和温里药各4种、平肝息风药3种、理气药1种。从专业角度对配伍中药重新分析发现,仲景经方治疗糖尿病周围神经病变主要与活血化瘀类、益气滋阴清热类、祛风利湿类、温经发散通络类共四大类药物联合配伍使用。进一步分析中药归经所属发现,以五脏尤其是肝、脾为最多。三、研究结论1、经方治疗DPN的上述三方证中,局部麻木、疼痛、肢体活动不灵3症经卡方检验未见差异。此3症状在DPN中亦最明显而常见。其余畏寒肢冷、神疲乏力、腹胀、口淡不渴、头晕、面色无华6症状作为多见症,均可作为仲景经方治,糖尿病周围神经病变的常见症,这对临床诊治有重要参考价值。这符合古代医家关于“痹证”“血痹”的诊断,也符合后世医家普遍认为其治“法在救阳”的观点。2、通过仲景伤寒经方配伍用药的频数分析、卡方检验比较,三经方证原方药物影响因素未见明显差异。分析表明,伤寒经方配伍用药之趋同趋势明显最多见温阳补虚和活血化瘀类药物联合配伍使用。研究证明,伤寒经方治疗糖尿病周围神经病变临床疗效较好,可信度高。本研究相关的症状诊断及治疗用药分析结果可用于指导临床实践。特别是仲娥黄芪桂枝五物汤、当归四逆汤等方更具中医特色,更切合DPN临床诊疗实践。其重温阳补气,活血化瘀及温经通络之法,对复杂而难治的DPN有更好的借鉴和指导意义。更多还原

【Abstract】 Diabetic peripheral neuropathy (DPN) is the commonest complication of diabetes. It may lead to the dysfunction of the sensory nerve, motor nerve, and autonomic nerve. Currently, there are no effective measures to prevent such adverse development. Zhang Zhong-jing’s Shanghan (Treatise on Exogenous Febrile Diseases) is a treasure trove. It ranks first in the science of TCM prescription not only for its perfect match, fine composition, and precision in the use of herbs but also its healing effects. This research adopts an analytical approach on the review of past medical literatures together with modern statistical methodology. Conducting a conclusive analysis on the treatment of diabetic peripheral neuropathy, I summarize my research and findings below:Ⅰ. TCM Literature StudyStarting from a comprehensive review and consolidation of TCM literatures on diabetic peripheral neuropathy,1summarized and analyzed: the pathogenic factors, pathogenesis, clinical diagnosis and treatment (including special treatment, external treatment, acupuncture&moxibustion etc.) in the context of Zhang Zhong-jing’s historic background and development. This coupled with other TCM literatures and modern clinical development formed the basis of this research.Ⅱ Research on the Routines of Syndrome Differentiation&Treatment1. Purpose of the ResearchIt was evident that the application of Zhang Zhong-jing’s classical prescriptions significantly improved patient’s syndromes and physique thus elevating the patient’s quality of life. Nowadays, renowned clinical and laboratory results were achieved. Collating the massive successful cases of DPN treated with traditional prescriptions, it is the aim of this research to consolidate and to conclude a stage of achievement to facilitate possible future research development and advancement.2. Research MethodologyBased on the databanks of China National Knowledge Internet (CNKI) and China Science&Technology Journal (CSTJ), I chose Zhang Zhong-jing’s three prescriptions namely:Huangqi Guizhi Wuwu Tang,(HGWT-Decoction of Five Ingredients), Danggui Sini Tang (DST-Decoction of Chinese Angeli for Restoring Yang) and Shenqi Wan (SQW-Pill for Invigorating Kidney Qi) as the representation prescriptions in the treatment of DPN. To carry out a systematic research and analysis, I have constructed a database using normative data with frequency analysis, factor analysis and Chi-squarod test etc.3. The Results of the ResearchIn the frequency analysis, it showed a frequency of>5%indicated syndromes of DPN for17cases treated with HGWT,16cases treated with DST, and22cases treated with SQW. To identify the potential affects due to prescriptions and syndromes by means of factor analysis, it showed that: HGWT caused localized limbs discomfort, Qi deficiency and stomach discomfort etc.; DST caused localized discomfort, both Qi and Yang deficiency, abdominal discomfort and blood circulation deficiency; SQW caused localized discomfort, both kidney and Yang deficiency, Qi discomfort, stomach discomfort and neuropsychi atric symptoms etc. Using Chi-square test, it showed the following9common syndromes:localized numbness and pain, ineffective limbs activities, aversion to cold, lassitude, abdominal distension, mouth thirst, dizziness, lusterless and pale complexion etc.With the changes in era, the application of classical prescriptions also varied and evolved with special characteristics. For example, the original prescription was smaller in dosages and there were frequent uses of Quizhi. Statistics also revealed that in the appropriate choice of drugs and doses: for x2>5%, there were54drugs; for paired comparison method, there were14drugs to invigorate deficiency,11drugs to regulate blood circulation,7drugs to eliminate dampness,6drugs to clear away heat,5drugs to relief exterior syndromes,4each to promote diuresis&to eliminate dampness and to warm the interior;3drugs to calm the liver and stop endogenous wind;1drug to regulate the Qi. From professional standpoints, a review on the analysis of the composition of drugs showed that classical prescriptions excelled in the treatment of DPN in4major categories, namely:to promote blood circulation and to remove blood stasis; to invigorate Qi and to nourish Yin while eliminating heat; to dispel wind and to eliminate dampness; to warm the meridians and to promote blood circulation. A further study on the meridians where the drugs took effect revealed that the treatment focused on both the liver and spleen.Ⅲ Conelusion1. Classical prescriptions indicated that there were syndromes of localized numbness, localized pain and inactivity of the limbs. In Chi-square test, here was no exception and this could be viewed as an obvious symptom. These other six obvious symptoms were:aversion to cold, dispiritedness and lassitude, abdominal distension, mouth thirst, dizziness and pale complexion. All these could be summed up to signify the pathological changes and transmission rules of DPN diseases. These findings correlated with most TCM practitioners’belief that "Shanghan’s primary is to save Yang"2. Using normative data with frequency analysis, factor analysis and Chi-squared test etc. it was found that the drugs of Zhang Zhong-jing’s original three classical prescriptions varied only slightly. I opined that Shanghan’s classical prescriptions were as effective today as they were in the past in terms of composition and modification.It was evinced that Shanghan’s classical prescriptions were effective in the treatment of DPN diseases. It was intended that the findings of the TCM diagnosis and treatment in this research might serve as a guide in clinical practice.更多还原